Alabama Medicaid Provider Enrollment

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ALABAMA MEDICAIDAGENCYAttachment APATIENT 1st HOSPITAL ADMITTINGAGREEMENTPatient 1 st Primary Medical Providers (PMPs) are required to establish and maintain hospital admittingprivileges or have a formal arrangement with a hospitalist group or another physician or group for themanagement of inpatient hospital admissions that addresses the needs of all enrollees or potential enrollees. If aPMP does not admit patients, then the Patient 1 st Hospital Admitting Agreement form must be submitted to theAgency to address this requirement for participation. If the Patient 1 st provider has entered into a formalarrangement for inpatient services, this form must be completed by both parties, and the applicant mustsubmit the original form with the application for enrollment or within 10 days of when a change occursregarding the provider’s management of inpatient hospital admissions.A formal arrangement is defined as a voluntary agreement between the Patient 1 st PMP and the agreeablephysician/group. The agreeable party is committing in writing to admit and coordinate medical care for thePatient 1 st enrollee throughout the inpatient stay. Admitting privileges or the formal arrangement for inpatienthospital care must be maintained at a hospital that is within a distance of thirty (30) miles or forty-five (45)minutes drive time from the Patient 1 st PMP’s practice. If there is no hospital that meets the above geographicalcriteria, the hospital geographically closest to the Patient 1 st PMP’s practice will be accepted.Exception may be granted in cases where it is determined the benefits of a provider’s participation outweigh theprovider’s inability to comply with this requirement.To ensure a complete understanding, the Patient 1 st Program has adopted the Patient 1 st Hospital AdmittingAgreement. This agreement serves as a formal written agreement established between the two parties asfollows:• The Patient 1 st Primary Medical Provider is privileged to refer Patient 1 st patients for hospital admission. Thebelow named provider is agreeing to treat and administer to the medical needs of these patients while they arehospitalized.• The below named provider will arrange coverage for Patient 1 st enrollee admissions during their vacations.• Either party may terminate this agreement at any time by giving written 30 days advance notice to the other partyor by mutual agreement.• The Patient 1 st Primary Medical Provider will notify the Patient 1 st program in writing of any changes to orterminations of this agreement.• The Patient 1 st Primary Medical Provider will provide the below named provider with the appropriate paymentauthorization number.Physician and/or Group Agreeing to Cover Hospital AdmissionsPhysician/Group Name: ____________________________________ NPI Number___________________________Mailing Address: _______________________________________________________________________________________________________________________________________________________________Specialty: ______________________________________________ Ages Admitted: _________________________Hospital Affiliation(s) and Location(s): __________________________________________________________________________________________________________________________Contact Person: ______________________________________________ Telephone Number: _________________Authorized Signature: __________________________________________________ Date: ____________________Questions regarding hospital admitting privileges may be directed to the Patient 1 st Program.Patient 1st 10 Revised September 2009
ALABAMA MEDICAID AGENCYAttachment BEPSDT AGREEMENTFor recipients of Medicaid, birth to age 21, the Early, Periodic Screening, Diagnosis and Treatment (EPSDT)examination is a comprehensive preventive service at an age appropriate recommended schedule. There arenumerous components of the EPSDT, and are listed and described in Appendix A of the Alabama MedicaidProvider Manual.If a PMP cannot or chooses not to perform the comprehensive EPSDT screenings, this agreement allows the PMP tocontract with another Medicaid Screener (hereinafter known as Screener) serving the PMP’s area to perform thescreenings for enrollees in the birth to 21 year age group.The agreement requires the PMP to:1. Refer Patient 1 st patients for EPSDT Screenings. If the patient is in the office, the physician/office staffwill assist the patient in making a screening appointment with the Screener within 10 days.2. Maintain, in the office, a copy of the physical examination and immunization records as a part of thepatient’s permanent record.3. Monitor the information provided by the Screener to assure that children in the Patient 1 st program arereceiving immunizations as scheduled and counsel patients appropriately if found in noncompliance withwell child visits or immunizations.4. Review information provided by the Screener to coordinate any necessary treatment and/or follow up carewith patients as determined by the screening.5. Immediately notify the Agency and EDS of any changes to this agreement.The Screener agrees to:1. Provide age appropriate EPSDT examinations and immunizations within 60 days of the request forpatients who are referred by the PMP or are self-referred.2. Send EPSDT physical examination and immunization records within 30 days to the PMP.3. Notify the PMP of significant findings on the EPSDT examination or the need for immediate follow-upcare within 24 hours. Allow the PMP to direct further referrals for specialized testing or treatment.4. Immediately notify the Agency and EDS of any changes to this agreement.If the PMP chooses to utilize this agreement in order to meet this Patient 1 st requirement for participation, theagreement containing the original signatures of the PMP or the authorized representative and the screener or anauthorized representative must be submitted within the enrollment application. The PMP must keep a copy ofthis agreement on file. If this agreement is executed after enrollment, a copy must be submitted to EDS within10 days of execution.This agreement can be entered into or terminated at any time by the PMP or the screener. The Agency and EDSmust be notified immediately of any change in the status of the agreement. Questions regarding this agreementcan be addressed to EDS.By signing the PMP agreement and below, both the PMP and the Screener agree to the above provisions.____________________________________________Signature of Screener/Designee____________________________________________Printed Name of Screener/Designee____________________________________________Signature of PMP___________________________________Date___________________________________Screener NPI Number___________________________________PMP NPI NumberPatient 1st 11 Revised September 2009
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Alabama Medicaid Provider Enrollment

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